The Effect of Oral Health Educational Intervention Program among Mothers of Children aged 1-6, Based on the Theory of Planned Behavior

Statement of the Problem: Oral self- care is an important aspect of lifestyle and a serious public health issue. Purpose: This study aimed to evaluate the effect of an educational program based on the theory of planned behavior (TPB) on the mothers and children’s oral self-care behaviors. Materials and Method: This quasi-experimental study was conducted on 148 mothers and their children (1–6 years) who referred to the health centers of Tabriz, Iran ; divided into two groups of intervention (n=74) and control (n=74). Data were collected through a questionnaire that included demographic characteristics, oral self-care behaviors, and structures of TPB. Both groups completed questionnaires before, immediately, 3 and 6 months after the intervention. The experimental group received three educational sessions, each session held for 120 minutes. The educational methods such as lectures, group discussion, and demonstrations were used. Data were analyzed using SPSS (ver18) software and Chi-square, Independent samples t-test and repeated measure ANOVA at the significant level of < 0.05. Results: Before the intervention, there were no statistically significant differences between both groups in oral self –care behaviors and structures of TPB (p> 0.05). Immediately, 3 and 6 months after the intervention the mean scores of oral self-care behavior presented a significant increase in both mothers and their children in the intervention group (p< 0.001). Six months after the intervention, brushing children’s teeth twice a day increased significantly from 8.1% (6/74) to 55.4% (41/74) in the experimental group (p< 0.001). At immediately, 3, and 6 months after the intervention, the mean scores of mothers’ attitude, subjective norm, perceived behavioral control and intention towards the children’s oral health were significantly increased in the experimental group compared to the control group (p< 0.001). Conclusion: According to the results of this study, intervention based on the theory of planned behavior promotes the oral self-care behavior both in mothers and in their children.

lem, and about 60-90% of schoolchildren and the vast majority of adults are affected by dental caries [2]. According to the national oral health survey, 89% of the 6-year-old children have had dental caries experience [3].
In addition, the prevalence of dental caries among preschool children was reported 70% in the study of Shaghaghian et al. in Shiraz [4]. In a study by Gharlipour et al. [5] decayed, missing, and filled teeth (dmft) scores were 5.49±3.6 in Iranian preschool children.
Oral self-care behaviors are necessary for the oral health promotion [6]; oral self-care habits such as tooth brushing, dental flossing, and regular dental visits are recommended for good oral health and prudential health [7][8]. The recent study in Iran showed that 25.0% of children never brushed their teeth, which indicates a poor oral self -care in children [9].
Studies reported the positive effect of mothers' oral health behaviors on their children's oral health, and mothers' tooth brushing was a significant indicator for the tooth brushing behavior of their children [9][10].
Based on previous studies, a serious need for planning and performing appropriate programs to improve children's oral health behavior is highly suggested [5,[11][12]. Health education is a vital component in promotion of oral health [13]. Therefore, theory-based educational interventions are recommended to promote oral health habits [14][15][16]; they are more successful for changing and maintaining healthy behavior [17][18]. The theory of planned behavior (TPB) describes the main elements of healthy behavior and consists of five constructs including intention, attitude, subjective norm, and perceived behavioral control. The intention is formed by an individual's attitude towards the behavior, subjective norm, and perceived behavioral control.  [12,20]. For instance, the frequency of tooth brushing were asked, and the given score ranged from 0(Irregularly or never) to 4(twice daily or more). The possible score range was 0-11 and the higher score indicated the higher oral health self-care behaviors.
In part three, the constructs of TPB related to oral health was assessed through 18 questions [20]. The items are presented in Table 1 Table 2.

Ethical consideration
The Ethical Committee of Isfahan University of Medical Science, Iran, approved the study protocol (ID number-93-393296). The purpose of the study was explained to the participants, and a written consent was then obtained from participating mothers who volunteered to enter this study.

Inclusion and exclusion criteria
The eligibility criteria for inclusion was having profile in health centers, willing to participate in the study, not suffering from special mental and emotional diseases (concerning their medical profiles). Exclusion criteria were the failure to complete three educational sessions and the lack of desire for participation.

Data Analyses
SPSS version 16 (SPSS, Inc., Chicago, IL, USA) statistical software was used to analyze the data. Descriptive statistics were performed to assess the means and standard deviation for quantitative variables and frequencies

Presentation by Time Activity and learning objectives
Health care provider 100-120 min Session1: Get to know each other, the purpose of the study was explained to the participants, mothers were asked to share their information related to their children's oral health, basic knowledge regarding the etiology of development and prevention of oral diseases. Mothers who were successful in cleaning their child's teeth shared their experience with others in the session. At the end of session: Feedbacks were provided; each mother was encouraged to ask questions. They were recommended to practice good oral health care for both themselves and their children at home. They received a motivational message: children should clean their teeth and gums every day. Teaching method: Interactive lecture, discussion group, questions and answers References: Pamphlets and booklets on oral health, approved by Iran's Ministry of Health and Education Dentist and Health care provider 150 min Session2: Review of main topics from previous session, general information related to role of oral health in child's health, difference between deciduous teeth and permanent teeth were explained, the importance of deciduous teeth, factors influencing on dental cavity, the ways of preventing dental cavity for infants and children were discussed. Brushing technique and dental flossing were demonstrated. Mothers were demonstrated the correct way to floss their children's teeth and informed how they could assist their children in brushing teeth. Children practiced brushing teeth with assistance of their mothers. At the end of session: Feedbacks were provided; each mother was encouraged to ask questions. They were recommended to practice good oral health care for both themselves and their children at home.

120-150
Session3: Review of main topics from previous session, the importance of nutrition on children oral health was explained. Some healthy snacks were described. They were informed that poor oral health could affect children's nutritional intake. The importance of regular dental visits, the vital role of fluoride, and the ways to obtain fluoride were explained. The mothers were encouraged to discuss their positive and negative beliefs about the oral health of children. The correct methods of tooth brushing and flossing were demonstrated to the children. Children practiced brushing teeth with assistance of their mothers (brushing practice).
Teaching method: Interactive lecture, discussion group, demonstration, questions and answers At the end of session: Feedbacks were provided; each mother was encouraged to ask questions. They were recommended to practice good oral health care for both themselves and their children at home.

References: Pamphlets and booklets on oral health, approved by Iran's Ministry of Health and Education
for categorical variables. Independent samples t-test for continuous variables and chi-square test for categorical variables were used to compare the demographic characteristics between the two groups. Independent samples t-test was used to compare the constructs of TPB and oral self -care behaviors score between two groups at baseline and follow-up (immediately, 3 months, and 6 months after the intervention). Repeated measure ANOVA was used to compare the constructs of TPB and oral health self-care behaviors in four measurements. For all tests, the significance level of α was considered as 0.05.

Results
The mean (SD) age of the participants was 29.4 (7.1) and 28.7 (6.4) years in the experimental and control groups, respectively. According to the independent samples t-test, the mean age of the participants was not significantly different between the two groups (t=0.44, p= 0.65). Socio-demographic characteristics of the participants are presented in Table 3. This finding showed that there was no significant difference between both groups in the terms of marital status (p= 0.49), occupation (p=0.6), education level (p= 0.97), economic status (p= 0.62),and number of family (p= 0.56). Table 3 Table 5.

As shown in
The results of the chi-square test showed a significant increase in the frequency of children tooth brushing in In the experimental group, the children brushing twicedaily was 8.1% (6/74) which increased to 55.4% (41/74) after the intervention (p< 0.001).

Discussion
Based on our knowledge, this study is one of the few theory-based interventions on oral self-care behaviors among both mothers and their children. According to our results, after the intervention, mothers 'attitude, sub-jective norm, perceived behavioral control, intention regarding oral health, and oral self-care behaviors (mother and child) of the experimental group was found to be significantly increased as compared to those who were in control group. Hence, it can be verified that theory-based intervention was effective in improving and maintaining the oral self-care behavior of both mothers and their children. This study showed the score of the children's oral self-care significantly increased in the experimental group after immediately, 3 and 6 mon-  Tooth brushing is an important aspect of child oral self-care; tooth brushing twice daily is recommended for children's oral health self-care [24][25]. On the other hand, parents are responsible for their children's oral hygiene and the mother's role is significant in this regard [12]. The results of this study showed that the score of the mothers' oral self-care behaviors has significantly increased in the experimental group after immediately, 3and 6 months of follow-up. This finding is consistent with several previous studies in this field that found a significant improvement on oral health self-care after intervention [26][27]. In another study, it was found that oral self-care skills scores were increased significantly after intervention among adolescents [28].
This study revealed that the experimental group had higher attitude toward oral self-care behaviors compared to the control group after the intervention. This finding is consistent with several previous studies [29][30].
Amin et al. [31] reported the positive effect of the intervention considering TPB on participants' attitude toward oral health behavior. One of the predisposing factors to achieve health-promoting behaviors is the attitude [8]. Some previous studies emphasized the role of mothers' attitude on their children's oral self-care behaviors, and subsequently on their children's oral health [20,32].
Similar to the findings of previous studies [27,[30][31], in the current study, after intervention, the mean score of perceived behavioral control towards children's oral health was increased significantly in the experimental group compared to control group. This finding is also consistent with a similar previous study by Hatefnia et al. [33] that found the positive impacts of theorybased interventions on maternal perceived behavioral control toward children's oral self-care. The results of current study showed that mothers' intention towards children's oral health increased in experimental group significantly compared to the control group. This finding is consistent with Jafari Baghkheirati et al. [30], Amin et al. [31], which reported positive effects of educational intervention on intention toward oral self-care. In addition, this finding is in line with another study that showed the positive impacts of interventions on maternal intention toward children's oral self-care [33]. There were some limitations to this study. Firstly, the questionnaire was self-reported that could be subjected to recall and social desirability biases. Secondly, there was no clinical examination for the outcome variable (oral self-care behaviors).

Conclusion
In conclusion, the results of this study showed that TPBbased education intervention program for mothers can increase their attitude, intention, perceived behavioral control towards children oral health and oral self-care of mothers and their children. Therefore, TPB-based interventions need to be considered in the preventive oral health program at health centers.
ahan University of Medical Science of Iran for their financial support. Authors would also thank the mothers for their participation and the personnel of health centers for their collaboration and help in this study.